Posterior approach to suboccipital-craniovertebral junction in patients with occipital pressure ulcer - Proposal of Y shaped occipito-cervical incision.

Dear Sir,

The median occipito-cervical incision [Figure 1] is quintessential in approaches to pathologies in midline posterior fossa, posterior rim of foramen magnum, and craniovertebral junction. It starts from the inion, and extends down to C2-C3 level, with subsequent dissection in the median avascular plane down to expose the suboccipital bone, C1 posterior tubercle, and C2 spinous process if required. It has several advantages. Incision is familiar to most neurosurgeons, blood loss is minimal, exposure is good, easy to perform, fast, and has excellent healing.

Figure 1

Standard median occipito-cervical incision

Occipital pressure ulcer is an unfortunate, but commonly encountered problem in patients who are either on skull traction, cervical collar, or bed ridden.[1] These are associated with various factors, and may vary from nonblanching skin erythema to loss of all layers of scalp, exposing underlying bone.[23] Pressure ulcers in this area may not permit standard midline incision, creating an impasse for the surgical management. Either we have to wait for the ulcer to heal or end up incorporating the ulcer in the incision enhancing the risk of infective complications. More often the pressure ulcers don’t heal unless the patient is mobilized without cervical collar. This predicament has never been discussed in the literature, despite its frequent occurrence.

In noninfected partial thickness pressure ulcers (Stages I–II), we propose and have used Y shaped incision, having a midline vertical limb, which stops around 3 cm below the pressure ulcer, and curvilinear limbs extending on either side of the ulcer from the topmost part of the vertical limb [Figure 2]. The incision is taken till the nuchal fascia, with the subsequent dissection following the median avascular plane, just as in the standard incision. The upper semicircular flap dissection may also be carried down till the bone, leaving a musculofascial cuff attached to the superior nuchal line, to facilitate closure in the end [Figure 3]. The exposure offered is excellent [Figure 4], and also heals well because of good vascularity of the region. Out of total five patients in whom we have used this method (three with implant), we have not encountered any significant surgical site infection.

Figure 2

Y shaped incision in a patient with occipital pressure ulcer

Figure 3

Diagrammatic representation of dissection following Y shaped incision

Figure 4

Good exposure offered by Y shaped incision in a patient with C1-C2 fusion

Hence, we propose this as a safe and effective alternative to the standard midline incision, in select patients with partial thickness and noninfected occipital pressure ulcers, especially in patients needing urgent posterior stabilization for early mobilization.